Arterial hypertension

Содержание

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Definition Arterial hypertension (WHO, 1999) is a constantly increased systolic (≥140

Definition

Arterial hypertension (WHO, 1999) is a constantly increased systolic (≥140 mmHg)

and/or diastolic BP (≥90 mmHg)
Secondary (symptomatic) AH is a hypertension, the cause of which can be revealed, therefore this is a syndrome of the underlying primary disease
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Definition Hypertension is defined as values ≥140 mmHg SBP and/or ≥90

Definition

Hypertension is defined as values ≥140 mmHg SBP and/or ≥90

mmHg DBP, based on the evidence from RCTs that in patients with these BP values treatment-induced BP reductions are beneficial.
RCT - randomized controlled trials
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Why do we take care of arterial hypertension? “Silent killer of

Why do we take care of arterial hypertension?

“Silent killer of XXI

century”
Major cardiovascular risk factor, that directly contributes to MI, CHF, cerebrovascular accidents, peripheral arterial insufficiency, and premature mortality
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What do we call “target organs”? CNS (Strokes 7-10 times more

What do we call “target organs”?

CNS (Strokes 7-10 times more frequent!)


Heart (MI 4-5 times more frequent!)
Eyes (exudates associated with retinal ischaemia or infarction)
Kidneys (proteinuria and progressive renal failure)
Peripheral arteries (aortosclerosis, aneurysms & atherosclerosis)
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Hypertension in the world 33% of the population in USA, 43-44% in Russia,more than 41,5 million.

Hypertension in the world

33% of the population in USA,
43-44% in

Russia,more than 41,5 million.
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Prevalence of hypertension Overall the prevalence of hypertension appears to be

Prevalence of hypertension

Overall the prevalence of hypertension appears to be around

30–45% of the general population, with a steep increase with ageing
(>65 years – 60 – 70 % )
A close relationship between prevalence of hypertension and mortality for stroke has been reported. The incidence and trends of stroke mortality in Europe have been analysed by use of World Health Organization (WHO) statistics.
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Report of World Health Organization In 2020 AD, 2.6 million Indians

Report of World Health Organization

In 2020 AD, 2.6 million Indians

are predicted to die due to coronary heart disease which constitutes 54.1 % of all CVD deaths
The Sentinel Surveillance Project, documented 28% overall prevalence of hypertension from 10 regions of India in the age group 20-69.
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Hypertension in Nigeria Prevalence of hypertension -28.7%. Hypertension prevalence was comparable

Hypertension in Nigeria

Prevalence of hypertension -28.7%.
Hypertension prevalence was comparable in

men and women (29.9% versus 28.0%).
Hypertension was more prevalent in semi-urban than rural villagers (32.9% versus 24.1%). 
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Hypertension: Predisposing factors Age > 60 years Sex (men and postmenopausal

Hypertension: Predisposing factors

Age > 60 years
Sex (men and postmenopausal women)
Family history

of cardiovascular disease
Smoking
High cholesterol diet
Co-existing disorders such as diabetes, obesity and hyperlipidaemia
High intake of alcohol
Sedentary life style
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Structure of the diagnosis of AH Primary (essential hypertension) or secondary

Structure of the diagnosis of AH

Primary (essential hypertension) or secondary

(symptomatic)
Degree (according to BP level)
Stage (depends on impairment of target-organs)
Stratification of risk for individual
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Structure of AH 94-95% constitute 5-6% - secondary AH 4-5% Renal

Structure of AH

94-95% constitute
5-6% - secondary AH
4-5%
Renal parenchimal
diseases
1-2% others

primary

AH (essential hypertension)
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Classification of AH according to the BP level (WHO, 1999) WHO-ISH

Classification of AH according to the BP level (WHO, 1999) WHO-ISH

Guidelines Subcommittee J Hypertens 1999; 17:151
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Classification of AH according to stages Stage I: no objective signs

Classification of AH according to stages

Stage I: no objective signs of

target organs affection
Stage II: objective signs of target organs affection but without its dysfunction:
LV hypertrophy (ECG, Echo, X-Ray), or
Generalized narrowing of arteries of the retina, or
Microalbuminuria, or proteinuria, or increased creatinin in plasma (<177 mcmol/l)
Stage III: objective signs of target organs affection with its dysfunction: stroke, hypertensive encephalopathy, hemorrhage in the retine,ACS,CHF, renal failure etc.
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Assessment of total cardiovascular risk The concept is based on the

Assessment of total cardiovascular risk

The concept is based on the fact

that only a small fraction of the hypertensive population has an elevation of BP alone, with the majority exhibiting additional CVrisk factors.
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Assessment of total cardiovascular risk Estimation of total CV risk is

Assessment of total cardiovascular risk

Estimation of total CV risk is easy

in particular subgroups of patients,such as those with antecedents of established cardiovascular disease (CVD), diabetes,CHDor with severely elevated single risk factors. In all of these conditions, the total CV risk is high or very high, calling for intensive CV risk-reducing measures. However, a large number of patients with hypertension do not belong to any of the above categories and the identification of those at low, moderate, high or very high risk requires the use of models to estimate total CV risk, so as to be able to adjust the therapeutic approach accordingly
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Assessment of total cardiovascular risk The classification in low, moderate, high

Assessment of total cardiovascular risk

The classification in low, moderate, high and

very high risk is retained in the current guidelines and refers to the 10-year risk of CV mortality as defined by the 2012 ESC prevention guidelines . The factors on which the stratification is based are summarized in next page.
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Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Male sex
Age

(men ≥55 years; women ≥65 years)
Smoking
Dyslipidaemia
Total cholesterol >4.9 mmol/L (190 mg/dL), and/or
Low-density lipoprotein cholesterol >3.0 mmol/L (115 mg/dL),
and/or High-density lipoprotein cholesterol: men <1.0 mmol/L
(40 mg/dL), women <1.2 mmol/L (46 mg/dL), and/or
Triglycerides >1.7 mmol/L (150 mg/dL)
Fasting plasma glucose 5.6–6.9 mmol/L (102–125 mg/dL)
Abnormal glucose tolerance test
Obesity [BMI ≥30 kg/m2 (height2)]
Abdominal obesity (waist circumference: men ≥102 cm;
women ≥88 cm) (in Caucasians)
Family history of premature CVD (men aged <55 years; women aged <65 years)
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Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Asymptomatic organ

damage:
Pulse pressure (in the elderly) ≥60 mmHg
Electrocardiographic LVH (Sokolow–Lyon index >3.5 mV;RaVL >1.1 mV; Cornell voltage duration product >244 mV*ms), or
Echocardiographic LVH [LVM index: men >115 g/m2;women >95 g/m2 (BSA)]
Carotid wall thickening (IMT >0.9 mm) or plaque
Carotid–femoral PWV >10 m/s
Ankle-brachial index <0.9
CKD with eGFR 30–60 mL/min/1.73 m2 (BSA)
Microalbuminuria (30–300 mg/24 h), or albumin–creatinine ratio (30–300 mg/g; 3.4–34 mg/mmol) (preferentially on morning spot urine)
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Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Factors—other than office BP—influencing prognosis; used for stratification of total CVrisk

Diabetes mellitus:
Fasting

plasma glucose ≥7.0 mmol/L (126 mg/dL) on two repeated
measurements, and/or HbA1c >7% (53 mmol/mol), and/or
Post-load plasma glucose >11.0 mmol/L (198 mg/dL)
Established CV or renal disease:
Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack
CHD: myocardial infarction; angina; myocardial revascularization with PCI or CABG
Heart failure, including heart failure with preserved EF
Symptomatic lower extremities peripheral artery disease
CKD with eGFR <30 mL/min/1.73m2 (BSA); proteinuria (>300 mg/24 h).
Advanced retinopathy: haemorrhages or exudates, papilloedema
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MEASUREMENT OF BLOOD PRESSURE Use a machine that has been validated,

MEASUREMENT OF BLOOD PRESSURE

Use a machine that has been validated, well

maintained and properly calibrated
Measure sitting BP routinely, with additional standing BP in elderly and diabetics
Remove tight clothing from the arm
Support arm at level of the heart
Lower mercury slowly (2 mm per second)
Read BP to the nearest 2 mmHg
Use phase V (disappearance of sounds) to measure diastolic BP
Take two measurements at each visit
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Types of measurement: Office BP Home BP Daily monitoring of BP!!!

Types of measurement:

Office BP
Home BP
Daily monitoring of BP!!!

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‘White coat‘ hypertension? Up to 13-15% of apparent hypertension in the

‘White coat‘ hypertension?

Up to 13-15% of apparent hypertension in the clinic

may 'normal BP' when it is recorded by automated used in their own home
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Classification of secondary AH 1. Renal: Renal parenchymal, Renovascular Anephric 2.

Classification of secondary AH

1. Renal:
Renal parenchymal,
Renovascular
Anephric
2. Endocrinological:
Cushing`s syndrome and disease
Primary aldosteronism
Pheochromacytoma
Primary

hypothyroidism
Hyperthyroidism
Acromegaly
Hyperparathyroidism
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Classification of secondary AH 3. Neurogenic: - In increased intracranial pressure

Classification of secondary AH

3. Neurogenic:
- In increased intracranial pressure (tumors,

inflammatory diseases)
Hypotalamic syndrome
4. Cardiovascular (hemodynamic):
Coarctation of aorta
Patent ductus arteriosus
Atherosclerosis of aorta
Insufficiency of aortic valve
Complete AV block
Congestive chronic heart failure
Polycytemia
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Classification of secondary AH 5. Pharmacological (iatrogenic) Corticosteroids Excessive thyroxine Oral

Classification of secondary AH

5. Pharmacological (iatrogenic)
Corticosteroids
Excessive thyroxine
Oral contraceptives, containing oestrogens
Sympatomimetics (for

ex. salbutamol),
Anabolic steroids,
Non-steroidal anti-inflammatory drugs,
Carbenoxolone
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Routine tests • Haemoglobin and/or haematocrit. • Fasting plasma glucose. •

Routine tests
• Haemoglobin and/or haematocrit.
• Fasting plasma glucose.
• Serum total

cholesterol, low-density lipoprotein cholesterol,high-density lipoprotein cholesterol.
• Fasting serum triglycerides.
• Serum potassium and sodium.
• Serum uric acid.
• Serum creatinine (with estimation of GFR).
• Urine analysis: microscopic examination; urinary protein by dipstick test; test for microalbuminuria.
• 12-lead ECG.
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Obligatory investigation to detect the secondary hypertension • Chest radiograph: to

Obligatory investigation to detect the secondary hypertension
• Chest radiograph: to detect

cardiomegaly, heart failure, coarctation of the aorta
Ambulatory BP recording: to assess borderline or 'white coat' hypertension
Echocardiogram: to detect or quantify left ventricular hypertrophy
Renal ultrasound: to detect possible renal disease
Renal angiography: to detect or confirm presence of renal artery stenosis
Urinary catecholamines: to detect possible phaeochromocytoma
Urinary cortisol and dexamethasone suppression test: to detect possible Cushing's syndrome
Plasma renin activity and aldosterone: to detect possible primary aldosteronism
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Life style modifications Lose weight, if overweight Limit alcohol intake Increase

Life style modifications

Lose weight, if overweight
Limit alcohol intake
Increase physical activity
Reduce salt

intake
Stop smoking
Limit intake of foods rich in fats and cholesterol
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Principles of treatment 1. Etiological: elimination of causes 2. Non-pharmacological treatment:

Principles of treatment

1. Etiological: elimination of causes
2. Non-pharmacological treatment: weight reduction,

stop alcogol and tobacco smoking, restriction of the sodium intake
3. Pathogenetic pharmacotherapy:
Long-term, lifelong administration of antihypertensive drugs
Long-acting drugs 1-2 times a day
Combined prescription of 2-3 preparations
β-blockers
Diuretics
Ca-blockers
ACE-inhibitors
Angiotensin II inhibitors
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Treatment strategies 1) Treatment is permanent and continuous 2) Begin treatment

Treatment strategies

1) Treatment is permanent and continuous 2) Begin treatment with a

minimal dose and gradually increase to reduce blood pressure 3) Gradually decrease of blood pressure 4) The choice of the drug taking accordingly hemodynamics, coronary insufficiency, arrhythmias, CVD risk factors, target organs damage, concomitant diseases 5) Stepwise therapy 6) Rational combinations 7) Prolonged drugs use
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Angiotensin II inhibitors ACE-inhibitors Diuretics Ca-blockers or + Top-priority combinations of AHT

Angiotensin II
inhibitors

ACE-inhibitors

Diuretics

Ca-blockers

or

+

Top-priority combinations of AHT

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Renal parenchymal AH: chronic glomerulonephritis, pyelonephritis, polycystic renal disease, diabetic nephropathy,

Renal parenchymal AH:

chronic glomerulonephritis,
pyelonephritis,
polycystic renal disease,
diabetic nephropathy,
congenital

diseases of kidneys,
vasculitis in systemic connective tissue diseases,
amyloidosis of kidneys,
renal tumors:
Manifestations:
pain in the loin,
intoxication and fever,
dysuria (frequent micturition, nocturia),
renal edemas, nephrotic syndrome,
symptoms of chronic renal failure,
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Diagnostics of renal parenchymal diseases urinary syndrome (proteinuria, leucocyturia, hematuria, cylindruria,

Diagnostics of renal parenchymal diseases

urinary syndrome (proteinuria, leucocyturia, hematuria, cylindruria, bacteriuria),
testing

of the renal function (glomerular filtration rate, isotopic renography),
instrumental diagnostics (excretory urography, USI of kidneys, radionuclide renoscintigraphy, MRI, biopsy)
Pathogenesis: involvement of the RAA system
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The renin-angiotensin-aldosterone system

The renin-angiotensin-aldosterone system

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Renovascular AH: stable and high BP level AH resistant to antihypertensive

Renovascular AH:
stable and high BP level
AH resistant to antihypertensive treatment

Atheromatous (old

men with widespread atherosclerosis)
Fibromuscular hyperplasia (proliferation of media – young women)
Arteriitis (Takayasu disease), thrombosis, aneurism, compression of the renal artery
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Diagnostics and treatment of renovascular desease Auscultation: murmur in the paraumbilical

Diagnostics and treatment of renovascular desease

Auscultation: murmur in the paraumbilical region


Renal arteriogram
Doppler-echocardiography of the renal vessels !!!!
CT
Renin level in renal vein
Treatment: Surgical revascularization (Renal percutaneous transluminal angioplasty)
Therapeutic (long-term antihypertensive drugs)
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Pheochromacytoma Rare tumor of chromaffin cells (adrenal medulla of the kidneys

Pheochromacytoma

Rare tumor of chromaffin cells (adrenal medulla of the kidneys or


the sympathetic ganglia in the abdomen or the chest) → hypersecretion of
norepinephrine and epinephrine → Arterial hypertension with crises
Clinical features:
Paroxismal sweating, flushing, palpitation
Orthostasis (↑BP in the supine position, ↓BP when standing up)
Weight loss
Intermittent or sustained hypertension
Fast reduction of symptoms by phentolamin
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Diagnostics and treatment of Pheochromacytoma Diagnosis: Elevated urinary excretion of vanillylmandelic

Diagnostics and treatment of Pheochromacytoma

Diagnosis:
Elevated urinary excretion of vanillylmandelic acid

(VMA) and metanephrine
Hyperglycemia, glucosuria
USI of kidneys
CT, MRI
Treatment: Surgical removal of the tumor + phentolamin, β-blockers
Слайд 41

Primary hypеraldosteronism (Conn`s syndrome) Adenoma of the adrenal, or adrenal hyperplasia

Primary hypеraldosteronism (Conn`s syndrome)

Adenoma of the adrenal, or adrenal hyperplasia
Oversecretion of

aldosterone
↑ excretion of K+ + retention of Na+ and H2O → hypokaliemia, ↑ stroke volume → ↑BP
Clinical features (!women below age 40years):
sometimes non-specific (mild or moderate AH)
symptoms related to potassium depletion (nocturia, polyuria, thirst, muscular fatigue and paresthesias, arrhythmias)
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Diagnostics and treatment of Conn`s syndrome Diagnosis: Hypokaliemia ( ↓ Renin,

Diagnostics and treatment of Conn`s syndrome

Diagnosis:
Hypokaliemia (<3,5 μmol/l), ↑ Na+

in serum
↓ Renin, ↑ Aldosterone in plasma
Identification of a tumor by USI, CT or adrenal scintiscan (I131)
Treatment of hyperplasia: Antihypertensive therapy including spironolactone (the aldosterone antagonist)
Treatment of adenoma: resection of the adrenal tumor
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Cushing`s disease & Cushing`s syndrome Cushing`s disease is a primary tumor

Cushing`s disease & Cushing`s syndrome

Cushing`s disease is a primary

tumor of the anterior pituitary gland → bilateral adrenal hyperplasia → oversecretion of cortisol → hypercortisolism → retention of Na+ and H2O, ↑ aldosterone production → ↑ circulatory volume → ↑BP.
All reasons of hypercortisolism without proved pituitary tumor are called
Cushing`s syndrome
Clinical features: 1) “moon” face, 2) central truncal obesity, 3) muscular weakness 4) purple striae, 5) acne, 6) hirsutism, 7) osteoporosis, 8) alopecia, 9) steroid diabetus, 10) mild or moderate AH
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Cushing`s syndrome “Moon-like” face Purple striae

Cushing`s syndrome

“Moon-like” face
Purple striae

Слайд 45

Diagnostics and treatment of Cushing`s disease Diagnosis: ↑ ACTH and Cortisol

Diagnostics and treatment of Cushing`s disease

Diagnosis:
↑ ACTH and Cortisol level

in the blood
Visualization of the tumor: X-Ray tomography, CT of the pituitary and adrenal glands
Hyperglycemia, glucosuria
Treatment: microresection of the tumor, chemotherapy, if no – metyrapone (inhibitor of synthesis)
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Hyperthyroidism (Graves disease) TSH receptor antibodies → stimulation of thyroid gland

Hyperthyroidism (Graves disease)

TSH receptor antibodies → stimulation of thyroid
gland →

influence of T3 and T4 on metabolism →
↑ Stroke volume → ↑ systolic BP
+ nervousness, irritability, sweating, weight loss, palpitations, fatigue, weakness, etc.
Clinical findings: exophthalmus, diffuse enlargement of the thyroid
gland, tachycardia, atrial fibrillation, hand tremor, Grefe`s, Kocher`s,
Shtelvag`s symptoms, etc.
Diagnosis: ↑ TSH, T3, T4, thyroxin in the blood
Increased uptake of I131 by the thyroid gland
USI, radionuclide scanning
Treatment: antithyroid drugs (carbimazole etc.), radioiodine treatment, subtotal thyroidectomy, β-blockers
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Acromegaly Pituitary adenoma → hypersecretion of growth hormone → Na+ retention

Acromegaly
Pituitary adenoma → hypersecretion of growth hormone
→ Na+ retention

→ bony overgrowth, hypertension
Clinical findings: 40-50-year-old men with general
coarsening of features: the nose and ears are enlarged, the
prominent jaw, the large zygomatic arches, supraorbital
ridges, the skin folds are exaggerated, a harsh voice +
diabetus mellitus, a nodal or diffuse goiter
X-Ray: hyperostosis
Blood: high level of growth hormone
Treatment: transsphenoidal adenoidectomy
Слайд 48

Cardiovascular (hemodynamic) AH: 1. Atherosclerosis of the aorta (↑ regidity of

Cardiovascular (hemodynamic) AH:

1. Atherosclerosis of the aorta (↑ regidity of aorta)
-

elderly and senile age
- ↑systolic AH (BP=180/80 mmHg)
- systolic murmur (aortic stenosis)
- signs of a general atherosclerosis: X-Ray, angiography, Echocardiography, MRI
2. Aortic insufficiency (rheumatism, infective endocarditis, syphiis):
- dizziness, syncope, heart pains
- BP=140/10 mmHg
- rough diastolic murmur over the 2nd intercostal space on the right
- Echo-, Doppler echocardiography
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Cardiovascular (hemodynamic) AH: 3. Coarctation of the aorta (congenital defect) -

Cardiovascular (hemodynamic) AH:

3. Coarctation of the aorta (congenital defect)
- hyperemia of

a face and a neck, hypertrophy of the upper part of the trunk, atrophy of legs)
- ↑ BP on arms, ↓ or equal on legs
- Echo: narrowing of aorta
4. Complete AV-block (↑ stroke volume): bradicardia+Morganii-Adams-Stocks attacks by ECG
5. Polycytemia (itch, diffuse hyperemia (plethora), splenomegaly, ↑erythrocytes, Hb)
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Neurogenic AH Traumas of a skull, meningitis, encephalitis, cerebral atherosclerosis, tumors

Neurogenic AH

Traumas of a skull, meningitis, encephalitis, cerebral atherosclerosis, tumors
Severe headaches,

dizziness, epilepsy
Signs of organic injuries of CNS, mental disorders
Ophtalmoscopy,
X-Ray of a skull, EEG, CT, MRA
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